Literally means “split mind”: a split from reality i.e., not Multiple Personality Disorder
Across the world, it affects ~1% of the population.
The onset tends to be between 18 and 25 yrs. - having to leave home = stressful time
Different times of onset
Chronic Onset (“Chronos” = time)
There is often a subtle change in a normal young person who gradually loses drive and motivation, and starts to drift away from friends. After months or years of deterioration, more obvious signs of disturbance, such as delusional ideas or hallucinations appear.
Acute Onset (“Acute” = sharp, pointed)
Obvious signs such as hallucinations appear quite suddenly, usually after a stressful event, and the individual shows very disturbed behaviour within a few days.
Or it can come on somewhere in between - very vague
DSM-IV diagnoses schizophrenia if the person shows two or more symptoms for a period during one month:
•Grossly disorganised or catatonic behaviour
Types of schizophrenia
Positive symptoms (Type 1): Occur in addition to “normal functioning”.
Negative symptoms (Type 2): Occur to detract from “normal functioning”.
Positive Symptoms: Delusions
Bizarre beliefs that seem real to the person with schizophrenia, but are not real. Can’t be persuaded with evidence. (e.g., that you’re dead)
(nb. Doesn’t include religious, philosophical, or scientific beliefs)
Paranoia: being persecuted
Grandeur: inflated sense of importance
Reference: Behaviour/comments of others (or TV) are meant for them alone.
Positive Symptoms: Hallucinations
Hallucinations are important for the diagnosis of Schizophrenia as they occur more often in Sz than they do in other disorders.
Affective (emotional) flattening
Affective (emotional) flattening
A reduction in the range and intensity of emotional expression. E.g., facial expression, voice tone, eye contact and body language.
Poverty of speech. e.g., lessening of speech fluency and productivity, thoughts to reflect slowing or blocked thoughts.
The reduction of, or inability to, initiate and persist in goal-directed behaviour (for example, sitting in the house for hours every day, doing nothing). It is often mistaken for apparent disinterest.
Standing motionless like a statue, or adopting odd/bizarre postures. Similarly, patients often adopt ‘odd’ postures or give strange facial ‘grimaces’.
Incoherence – Repeated references to ideas with little or not connection.
Loose associations - Conversation drifts from past to present with no clear context.
Derailment - Difficulty staying on the same topic of conversation.
Here, the patient may show emotional responses that seem out of context.
“Silliness and laughter out of context”.
Bad news smiles and laughter, simple questions annoyed.
Types of Sz: Crow 1985
Type I syndrome: Acute with positive symptoms
Type II syndrome: Chronic with negative symptoms
Types of Sz
Paranoid: delusions of grandeur &/or persecution, hallucinations
Catatonic: excitability (sometimes aggressive) contrasted with catatonia.
Disorganised: mild auditory hallucination, delusions, thought process disorders and disturbances of affect. Behaviour can appear bizarre.
Residual: Those who had once experienced Sz, but no longer do (maybe a few positive symptoms).
Undifferentiated: Miscellaneous. Symptoms don’t fit into other categories.
Issues with classification and diagnosis:
Includes reliability and validity
Diagnosis: do you have schizophrenia in the first place
Classification: what type of schizophrenia
Reliabilty: consistency; consistant diagnosis and symptoms - the as in a few weeks time
Validity: It measure what it claims to measure
Issues with Classification
Serious Overlap of symptoms between types of Sz.
Comorbidity of Sz with other Mental illnesses.
The problem of Schizotypal Personality Disorder.
Issues with classification: Self report measures
The questionnaires usually include ambitious questions as it means one thing to you but another to the patient -ambiguity in answer
Investigator bias - mind set about patient being paranoid - keep on questioning them on it
Issues with classification; Serious Overlap of symptoms between types of Sz.
Paranoid - most types
Hallucinations - all
May affect reliability not a consistant diagnosis from different doctors -subjective opinion -lack inter-reliability
Lack validty if symptoms overlap its hard to get right what type of sz you have
Issues with classification Comorbidity of Sz with other Mental illnesses.
means sz can occur with another mental illness - most likely depression as they overlap with sz such as negative symptoms
Sim et al 2006: studies 142 hopitalised sz patients 32% had an additional mental illness
Those 32% didn't recover as well as those that didn't have comorbidty
Take the symptoms of depression for sz and place them in the wrong category which would lead to the wrong treatment -lack of validity
Issues with classification: The problem of Schizotypal Personality Disorder.
DSM-IV-TR schizotypal personality
Overlaps a lot with schizophrenia such as the symptoms are
odd thinking and speech etc
reduces validty as it may mean its not a valid diagnosis
Chapman et al. (1994)
Chapman et al. (1994)
Found that people who scored higly on schizotypal personality were more likely to develop full-blown schizophrenia within the next 10 years
Practical Issues with diagnosis
Beck et al. (1962)
Soderberg et al. (2005)
Sz isn’t one mental illness
theres extremes in sz as the negative symptoms are very different compared to positive symptoms
Probably to separate mental illnesses yet we give them the same label and treat them the same - lack inter-reliability -symptoms aren't consistant within sz
Lacks validity - may mislabel the person low reliability because of the subjective nature of the diagnosis - relies on one persons opinion - tested by using inter-reliability
Beck et al. (1962) and Soderberg et al. (2005)
Beck et al. (1962) reported a 54% concordance rate between practitioner’s diagnoses when assessing 153 patients, while Soderberg et al. (2005) reported a concordance rate of 81% using DSM-IV. This suggests classification systems have become reliable over time.
However some studies found inter-reliability as low as 0.114 - little predictive validity - don't know whether there positive or negative symptoms
Argues that very few causes of mental disorder are known and there is only a 50% chance of predicting what treatment a patient will receive based on diagnosis, suggesting diagnosis of schizophrenia has low validity.
Sent 8 healthy people (5m+3f) went to 12 psychiatric hospitals
Auditory hallucinations - 'empty', 'hallow' and 'thud'
7 were admitted, they acted normally and on average took 19 days to be released (7 to 52 days) - released with a diagnosis of sz in remission
He then said to a hospital that he would send more 'pseudopatients' to see if they could spot them. the hospital reported 41 genuine patients were fake - he sent no fake patients
Lacks validity: shows they don't understand sz properly - weren't able to detect that people didn't have sz BUT good inter-reliability 7/8 got admitted - consistant
Inconstistancy and a unreliable measure of treatment - detecting that they were not insane - large range 7 -52 days - cant predict it
The DSM has changed -increase reliability
lacks temporal validity - this would not represent what would happen today
Sociological Issues with Diagnosis
Sz is more common in African-Americans and African-Caribbean populations than in other groups (Harrison et al. 1988).
Reasons why: because of stress of moving to a different group - building a new life
segregation - big gap in the amount of income black and white people can earn
Racisim - to label certain groups with a mental illness because they are not the same as white people
Sociological Issues with Diagnosis studies
Cole & Pilisuk (1976)
Black people more likely to get drug treatment and less likely to get psychological treatment.
West Indian men are less likely to go to GP with a psychiatric issue, but are more likely to be admitted to psychiatric hospital.
Lipsedge & Littlewood (1979)
Psychotic black patients are twice as likely to be ‘sectioned’ than native or immigrant whites.
Sociological Issues with Diagnosis evaluation
Culture has changed - people are more equal - may mean if this was done today the findings would be different
Biological explainations: Genetics
The more genes you share with a aperson with sz the more like you will get it too.
Therefore there is a genetic compound to sz.
BUT sz must have some enviromenet factors as if it was 100% gnetic then if you shared 100% same genes (MZ twins) if would mean you would 100% get sz
Genetic studies (biological explanations)
Tienan et al 1991
Wahlberg et al 1991
Torrey 1992 found:
MZ: 28% (identical twins)
DZ: 6% (non-identical twins)
BUT we must remember that they usually have shared the same environment
Tienan et al 1991
155 mothers who had given up their child for adoption
Compared to 155 children adopted from non-sz parents 10.3% of those with sz mothers developed sz 1.1% of those with non-sz parents developed sz
Wahlberg et al 1991
Followed up Tienan and compared the adopted environment.
He found that the chances of developing sz was also dependent on the amount of communication deviance.
Thus theres a genetic and environment interaction.
Biochemistry: Andreason et al 1987
Findings showed that the more frequently you smoke cannabis the more chance of you developing sz.
It also showed if you have smoked weed more than 50 times it has more than quadrupled the chances
Might mean that someone who is going to develop sz is the kind of person to smoke cannabis – correlation is not causation.
The dopamine hypothesis
1.over production of dopamine
2.over sensitive receptors
3.poor regulation of dopamine
antipsychotic drugs block dopamine receptors and seem to work
patients who take L-dopa (increase dopamine) for Parkinson disease can exhibit sz symptoms
Amphetamines increase dopamine levels and can cause hallucinations and paranoia
Dobtmortems of sz patients show greater density of dopamine receptors in parts of the brain
Some studies show that sz have lower levels of dopamine in certain areas of the brain
The dopamine hypothesis studies
Cafisson 1999: implicates other neurotransmitters in the development of sz (e.g. serotonin and glutamate)
Vakammen (1977): some studies report that amphetamines can reduce sz symptoms
Kety 1975: L-DOPA and anti-psychotic drugs have a similar therapeutic value
Falkai et al 1988: Autopsies have found that people with sz have a larger than usual number of dopamine receptors increasing dopamine activity and receptor density (left amygdala and caudate nucleus putamen) Concluded that DA production is abnormal for sz
Evaluation for dopamine hypothesis
There is a lack of correspondence between taking the drugs and signs of clinical effectiveness.
It takes 4 weeks to see any sign that the drugs are working when they begin to block dopamine immediately.
We cannot seem to explain this time difference – shows that dopamine cannot soley affect sz otherwise it would be cured immediately
Biological Treatments banner headline
According to the Biological approach, Sz is caused by physical issues with the brain.
Therefore therapy will be something that changes the brain. e.g., drugs change the effectiveness of neurotransmitters in the brain. ECT stimulates the brain.
Issues with drugs
People become reliant on them - cant cope without them
30% dont respond to them
e.g., Thorazine and Haldol
Aka. Neuroleptic. Reduce positive symptoms but can produce symptoms linked to neurological diseases.
Reduces Dopamine activity within 48 hrs. Although takes a few weeks to work, are generally considered to be effective in reducing positive symptoms.
Sampath et al. (1992)
Typical Antipsychotics reduce positive schizophrenic symptoms in the majority of patients and appear to be a more effective treatment for schizophrenia than any of the other treatments used alone.
Doesn’t work with Negative
Sampath et al. (1992)
Patients that had been taking neuroleptics for 5 years either:
Went on to a placebo -75% relapsed within a year.
Continued on the drug - 33 % relapsed within a year.
Blurred Vision (16%)
Neuroleptic Malignant Syndrome (2%)
Tardive Dyskinesia (>20%)
Atypical antipsychotic drugs
e.g., Clozaril & Olanzapine
They work in a similar way to typical drugs but they also work on serotonin.
Have fewer side effects.
Can help people who did not respond to the Typical.
Atypical drug studies
Awad & Voruganti (1999)
Remington & Kapur (2000)
Awad & Voruganti (1999)
Found that conventional drugs have fewer side effects than neuroleptic drugs
Helps 85% of sz patients compared to 65% given typical drugs (neuroleptic drugs) responded well to the atypical drug clozapine
effective - treats more patients -responding better
appropriate - seem to be more effective and work better
Remington & Kapur (2000)
Atypical drugs are more use in helping patients suffering mainly from negative symptoms
One of the side effects from taking clozapine 1-2% risk of this
Reduces white blood cell and the condition can be life threatening. However olanzapine doesn't cause this.
Drug treatment Effectiveness
Most effective therapy for treating schizophrenia.
It is a palliative treatment not curative good because it can stop side effects occuring so reduces extreme symptoms
Some patients become resistant to drugs.
Drug treatment Appropriateness
Evidence for a biological basis (e.g.,?), so a biological therapy is fitting.
The side effects potentially very serious. (e.g., argranulocytosis)
Compliance of patients taking medication can be low as effectively means you have failed -cant control yourself - dont feel you
It is a palliative treatment not curative.
There isn’t really a suitable alternative
put electrodes on temple
give them anaethetic and muscle relaxant
put a bung in there mouth - top stop them biting off there tongue
give them a shock 70-130v 0.5 seconds -seizure for 60 seconds
wake them up
Treatment 3-4 times a week for a couple of week
we dont use this anymore - historical treatment - people with sz who had epelipetic fits the seizure made them feel better temporarily
zero other treatments at the time so try anything
ECT Effectiveness studies
Tharyan & Adams (2005): did a meta-analysis on ECT treatments on Sz. It has short-term effects, although it wasn’t as effective as drugs. There were few long-term benefits.
Braga & Petrides (2005): reviewed 42 studies and found that ECT with drugs was a safe and effective treatment strategy, especially for those resistant to conventional treatments.
Chanpattanna (2007): gave ECT + drugs to patients who were found to be resistant to typical drugs.
Found a reduction in Positive Symptoms, improved quality of life and social functioning.
There was no effect (or even a worsening) of negative symptoms.
Only really works in combination with drugs.
Only really works for positive symptoms.
Only really works in the short-term.
Only really is palliative rather than curative.
Sz is a biological illness, and ECT is a biological treatment.
We don’t know how it works or what effects (damage?) it is having on the brain.
There are side effects such as memory loss, cognitive impairments, and brain damage.
Most Sz strongly oppose being given ECT, and so ethically are we able to force them?
It is palliative not curative, nor does it last for long, and it doesn’t work on Negative symptoms.
Frauds view on sz
Psychodynamic approach to mental illnesses are caused by issues in the unconisous mind, perhaps fixations from childhood consists of three major assumptions
1. Schizophrenics fixate at the oral stage due to harsh uncaring upbringing
2. Later in life, regression to oral stage means that they abandon the ego (reality principle) explaining their break with reality – delusions of grandeur and creation of neologism
3. The individual will still try to keep contact with the real world which results in further sz symptoms – hearing voices of god telling you are Alan sugar make the situation feel more real
Evaluations of fraud
There has been little research on frauds explanation
Most mothers of sz are not harsh and withholding as fraud assumped
Warning and Kicks 1965: found mothers of sz tend to be anxious; shy; withdrawn and incoherent. The mothers of sz tend to be inadequate in various ways but those assumed by fraud.
Its very complex explanation; it involves assumptions about fixation, regression, stages of psychodynamic development. There is very little support for any of these assumptions – we cant measure the unconscious mind without using subjective opinion. Therefore not a scientific approaches as it not objective or falsifiable
Social Causation Hypothesis
Some theorists have suggested mental illnesses among ethnic minority groups is due to the STRESS of moving country triggering a DIATHESIS for mental illness.
This theory can be linked to include people from lower class groups as well.
The harder and more stressful your life, the greater the risk of schizophrenia.
The cognitive approach says that the way you think about the world has gone wrong due to the cognitive thought process.
Selective attention - Mckenna
Self monitoring - Frith + McGuigan + McGuigan et al + Johns et al 2001
Theory of mind - Frith + Drury et al
Memory - Hemsly
He argued that many of the symptoms of sz occurs as a result of defect in selective attention (poor communication skills) symptoms such as disorganised speech, speaking uninformatively, delusions and hallucinations might all depend at least in part on the poor ability of a person with sz to concentrate
They cant pay attention to one particular thing
Frith 1992 – self monitoring
He argued that important cognitive factors are associated with the development of sz
Positive symptoms of sz (delusions of control and auditory hallucinations) might occur because individuals with self-monitoring so fail to keep track of their own intentions.
Regard their own thoughts as alien and as having come from someone else - explains auditory halluncinations
Frith 1992 – Theory of mind
He also argued that individuals with sz have another important cognitive defect – the ability to understand people mental state – theory of mind.
They lack this it could explain some of their delusions and also explain why paranoid schizophrenics are suspicious of other intention
Hemsly 2005 memory
Perception and memory fail to combine effectively in sz.
You don’t remember what your meant to do in our everyday lives, we used stored knowledge (much of it in the form of schemas) to allow us to predict what is going to happen next more generally memory helps to ensure that we attend to and perceive the most important stimuli in the environment – helps us keep track of our goals.
People with sz are often unable to predict what will happen next their concentration is poor and they attend to unimportant or irrelevant aspects of the environment
Generally their poor integration of memory and perception leads to disorganised thinking and behaviuor
The vocal cords of the patients with sz was often active during the time they claimed to be experiencing auditory hallucinations
Suggesting they mistook their own inner speech for that of someone else.
Supports poor self-monitoring –you’re creating the voices it’s just you’re not aware of it.
McGuigan et al 1996
They found patients who suffered with sz who had hallucinations had reduced activity in the parts of the brain that monitored inner speech
Supports self-monitoring because part of your brain is weaker/is active in sz
Drury et al
Found people with sz scored lowly on test which measures someones theory of mind.
Johns et al 2001
There was three groups; sz with hallucinations; sz without halluncination and a contrl group
There was also three conditions; reading aloud; distorted own voice; someone elses voices; distorted someone elses voice.
The difference within the group was that the sz couldn't tell it was there own voice being distorted - they thought there voices was someone else' but the control group could.
There was no group difference for the conditions for somone else voice and it being distorted. - don't know if there were good or bad.
This shows people with sz have poor self monitoring.
The 4 main findings:-
Sz more common in decaying innercity areas than poor rural ones.
Sz almost 7x more common in African-Caribbeans than whites.
Average Sz rates in Caribbean countries is similar to that in the UK.
2nd Gen African-Caribbean immigrants have a higher Sz risk than 1st gen.
The cognitive approach claims that as features of the disorder appear, such as hearing voices, individuals try to make sense of them by asking those around them to confirm the validity of what they are experiencing.
When the other people fail to confirm the reality of these experiences the schizophrenic person may come to believe that the others are hiding the truth.
This can lead to further delusions (especially of persecution).
Behaviourism banner headline
According to this approach the Social Learning Theory causes sz because Sz children develop Sz from imitating their parents/siblings.
Behavioural approach explains some symptoms
Disorganised behaviour: see someone else acting strange – they get attention; you copy to get attention and vicarious reinforcement.
Halluncinations: reporting halluncination you are rewarded with lots of attention –operant conditioning
Delusions: paranoia (same as halluncination)
Grandeu: look at people (popular/famous) thinking their the best – copy them then get rewarded with more attention – immitiation
AO2 Behaviourism approach
Its scientific as its objective because you can see someones behaviour and replicable
If your schizophrenic the symptoms aren’t rewarding – doesn’t explain people in the real world
It doesn’t take into account all factors ignored the biological factors – cant explain fully
Ullman and Krasner (1969)
Children with bad parents develop behaviours from any external stimuli they can find.
In some cases, these reinforce bizarre behaviour.
e.g., Delusions of grandeur, persecution, etc
e.g., If we all experience hallucinations, these people are rewarded for feeding them and making a big deal from them.
Once these develop, they are unintentionally reinforced by parents/peers/whoever. Or they can be self-reinforcing (e.g., negative reinforcement; it makes them special when otherwise they are “nobodys”)
Ullman and Krasner (1969)
Reported that staff in hospital paid more attention to those who displayed characteristics of the disorder. The patient saw that if they disobeyed and played up, the staff would make a fuss over them.
Evaluation of behaviourism
Behaviourism cannot explain why many Sz show similar symptoms without ever having witnessed such behaviour before,or why the disorder tends to first occur in late adolescence or early adulthood.
It assumes that Sz is only the expression of symptoms. i.e., they aren’t actually hallucinating, but are only being rewarded for reporting hallucinations.
Furthermore, Sz is distressing to have, and it is therefore unlikely that it is rewarding to have Sz.
Manifest content – thing you dream
Laten content –underlying cause
Identifying the manifest content to understand the latent content –purely subjective
Free association: Where you lay down and talk continuously to try figure out the underlying causes – talking freely without censorship – theorpist sits behind them so no reaction is seen
Hypnosis: Directly talk to the unconscious mind and access memory’s which would be lock
The Token Economy
Since Sz is a learned mental illness, treatment is by unlearning it.
Since the Behaviourist considers Sz to only be a set of observable symptoms, the therapy only aims to remove those symptoms.
Token Economy Effectiveness studies
Ayllon & Azrin (1968)
Hospitalised Female patients with Sz (mean time in hospital = 16 yrs) were given tokens for appropriate behaviours.
e.g., brushing hair, making beds.
The tokens were exchanged for activities such as watching films, extra visits to the canteen.
The mean number of chores increased from 5 to over 40.
This shapes the behaviour away from Sz symptoms, and towards more “normal” behaviour.
Paul & Lentz (1977) used the TE with long-term Sz patients. They developed social and work skills, were able to look after themselves, and symptoms were reduced.
Five years later, 98% of these patients had been discharged, compared to 45% in the control group.
Token Economy Effectiveness
They work to change behaviours in highly-structured institutions so long as the tokens are given.
Only deal with a few symptoms of Sz.
Produce more “normal” behaviours, but don’t really affect the mind of the people with Sz.
Token Economy Appropriateness
Can help with negative symptoms because they provide incentives for more active behaviours.
Dickerson (2005): they can then be used to prop-up more conventional treatments.
The “desired behaviours” are near-completely determined by the therapists/staff without consultation of the patients.
They don’t really deal with positive symptoms. They may suppress them, but they don’t treat them.
It only focuses on the behaviours, and doesn’t care about cognitive or biological features.
It doesn’t work outside of institutions, and the benefits stop on release.
Psychodynamic Treatments - Psychoanalysis
Bring the Oral fixation into conscious awareness and achieve insight.
Effectiveness of Psychoanalysis
Malmberg & Fenton (2009) reviewed psychodynamic therapies and found that they have little benefit unless used alongside drug treatments. i.e., psychoanalysis only works if you also are taking drugs…
May (1968) found that patients treated with this therapy with drugs had significantly better outcomes than those treated with the therapy alone.
Appropriateness of Psychoanalysis
The validity of the underlying psychodynamic theory is questionable. If this isn’t what causes Sz, then is the treatment effective?
Psychoanalysis is very expensive (per session, and needs many sessions!). Should the NHS fund this?
A more holistic approach that incorporates cognitive and behavioural components.
Cognitive: Aims to challenge and change maladaptive thought processes.
Behavioural: To challenge and demonstrate irrational thoughts about the world.
A simple form of CBT
Challenging delusions by asking for alternative explanations, followed by “reality testing” by planning out a task that will reveal the validity of the interpretations in the real world.
Coping Strategy Enhancement Tarrier (1987)
75% Sz who experience delusions and/or hallucinations used coping strategies. e.g., distraction, positive self-talk.
72% of these said that at least one was particularly effective, and those that used more strategies were the most successful.
Coping Strategy Enhancement (CSE)
1.Situation set up so therapist and client can work together to improve coping strategies.
2.Emphasises hallucinations and delusions do not make you mad since we all have them.
3.Select one hallucination / delusion.
4.Client given task (homework) to apply coping strategy to the hallucination / delusion.
5.Therapist and client devise ways to make coping strategy more effective.
Effectiveness CBT studies
Tarrier et al. (1993) tested CSE. These patients showed a reduction in positive symptoms compared to a control group. This improvement remained 6-months later.
However, there was a near-50% dropout rate in the treatment.
Pfammatter et al. (2006) - CBT showed moderate reduction in positive symptoms. However they couldn’t identify which parts of CBT were actually effective.
Furthermore, maybe the CBT seems better than a control group not because CBT works, but because people with Sz who don’t get treatment (or inadequate treatment) simply get worse (Turkington et al. 2003).
Many symptoms of Sz are cognitive in nature (e.g., ) so a cognitive based therapy is fitting.
Many people with Sz already use coping strategies so it is appropriate to build on these. It doesn’t remove symptoms, but helps them to cope with them.
It only works for certain positive symptoms.
It ignores the biological factors in Sz.
CBT doesn’t treat Sz, but only deals with the reaction to Sz. i.e., you still have it, but you’re not distressed any more.
Maybe CBT can help with the co-morbid mental illness.